Blue Cross Blue Shield Association Member Claim Form

Member Claim Form
Do not file prescription drugs on this form. Type or use blue or black ink to complete.
• Visit bcbsnc.com for prescription drug, dental and international claim forms, or call the toll-free number on your ID card.
Filing Requirements:
• Complete a separate claim form for each covered family member.
• Enclose itemized receipts and make copies for your records. See Section IV for required information.
• Do not file a claim if the provider is filing for the same services.
• Attach Explanation of Benefits if these services are covered by another insurance policy.
• Claims must be filed within 18 months from the date services were received, or they will be denied.
• Please see Section VI for mailing information.
Any claim filed without the required documentation listed above will be returned.
SECTION I: Patient Information
Subscriber
Number:
Please enter the subscriber number from your ID card.
Begin with
letter prefix
2 digits following member’s
name (see ID card)
First Name:
Patient’s Last Name:
Date
of Birth:
Sex:
SECTION II: Mailing Information
Male
Female
Middle Initial:
Relationship
to Subscriber:
Self
Child
Spouse
Other:
Please check here if address has changed.
Subscriber Name:
Address (Line 1):
Address (Line 2):
City:
State:
NC
ZIP Code:
SECTION III: Other Insurance Information
Please complete the information below if the patient is covered by another health insurance policy.
Does the patient
have other insurance?
Yes
No
Other health insurance
company name:
Other policy
number:
Other policy
holder’s name:
Other policy holder’s
employer name:
Please complete the information below if the patient is covered by Medicare:
Is patient
eligible for:
Medicare health insurance
claim number:
Part A
Part B
Part A and B
PLEASE NOTE: If your other insurance or Medicare policy is primary, you must attach a copy of the Explanation
of Benefits from that insurer. Your claim cannot be processed without this information.
An independent licensee of the Blue Cross and Blue Shield Association. ®,SM Marks of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina. BE236, 11/09
bcbsnc.com
SECTION IV: Services and Supplies To Be Considered For Reimbursement
These may include ambulance services, medical appliances, diabetic supplies, glasses and/or contact lenses or out-of-network services.
BCBSNC requires that procedure codes and diagnosis codes on the itemized receipt be supplied by the provider of
the service. Claims or itemized receipts received without the information below will be RETURNED.
Please indicate where services were rendered if not in North Carolina:
Country:
Currency Used:
Date of Service
Diagnosis Codes or Symptoms You
Sought Treatment For
Charge
Cold and Flu Symptoms
54.00
(MM-DD-YY)
01-05-07
Procedure Codes or Description of Service/Supplies
EXAMPLE:
Office Visit
SECTION V: Private Duty Nursing
Date of Service
(MM-DD-YY)
03-10-07
EXAMPLE:
Enclose a copy of your receipts for these services.
Name of Nurse
Indicate
RN, LPN or CNA
License Number
Hours
Worked
Charge
Ms. Jane M. Doe
LPN
123456
8
160.00
SECTION VI: Mailing Information
DID YOU REMEMBER TO:
MAIL THIS FORM, ITEMIZED RECEIPTS AND
EXPLANATION OF BENEFITS (if applicable) TO:
Blue Cross and Blue Shield of North Carolina
P.O. Box 35
Durham, NC 27702
•
•
•
•
•
Use blue or black ink to complete the form?
Attach the Explanation of Benefits, if applicable?
Attach itemized receipts?
Provide your signature below?
Keep a copy of this form and your receipts?
I certify that the information on this form is correct and the expenses incurred were necessary for the services filed.
Signature:
Date:
Daytime
Phone
Number:
Print Form